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Highlights

New algorithm for drug treatment of diabetes

A new one-page algorithm to guide treatment of patients with type 2 diabetes was released last week by the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE).

The algorithm, part of a larger consensus statement, stratifies patients by A1c level into three groups and suggests medication choices to achieve target glycemic control. The algorithm recommends beginning with monotherapy for patients with A1c levels between 6.5%-7.5%, dual therapy for those in the 7.6%-9.0% range, and, depending on symptoms and prior exposure to medication, insulin and possibly additional agents for patients with a level over 9.0%.

Medication choices are prioritized according to risk of hypoglycemia, safety, efficacy, simplicity, and anticipated degree of patient adherence, as well as the overall cost of care. The consensus statement also includes a chart summarizing the key benefits and risks of diabetes medications. Biguanides, DPP-4 inhibitors, incretin mimetics, thiazolidinediones, alpha-glucosidase inhibitors, sulfonylureas, meglitinides, bile acid sequestrants, amylin analogs and insulin therapy are included.

The resource is intended to assist primary care physicians, endocrinologists and others in the management of type 2 diabetes, according to an AACE press release. The consensus statement, which was published in the September/October Endocrine Practice, was developed by a group of 14 clinicians, clinical researchers, practitioners and academicians and is based on AACE/ACE guidelines.

Med school enrollment continues to rise

First-year enrollment in the nation's medical schools rose this year 2% over last year to nearly 18,400 students, according to the Association of American Medical Colleges.

Four new U.S. medical schools—FIU Herbert Wertheim College of Medicine, The Commonwealth Medical College, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, and the University of Central Florida College of Medicine—seated their first entering classes this year, accounting for half of the 2009 enrollment increase. In addition, 12 schools expanded their 2009 class size by 7% or more.

The AAMC also called for more residency training slots to prevent a bottleneck in training.

The pool of medical school applicants remained stable at 42,269, a slight increase over 2008's total of 42,231 applicants. Some other highlights:

Male enrollees (52%) outnumbered female enrollees (48%), although the number of women attending medical school has grown steadily since 1992;

Black applicants increased by 4% to 3,482, the largest number since 1999;

Hispanic applicants decreased 1% to 3,061.

It is unlikely that the current recession had an effect on the number of applicants to this year's entering class because these individuals applied to medical school between June and September of 2008. Early indicators such as the Medical College Admission Test suggest that next year's medical school applicant pool will show a continuing increase. From January to August of this year, more than 67,000 individuals took the MCAT exam, a nearly 3% increase over 2008.

Test yourself

MKSAP Quiz: reducing perioperative cardiovascular risk

A 78-year-old woman is evaluated one week before elective peripheral vascular surgery. She is a former smoker and has type 2 diabetes mellitus and peripheral vascular disease with left-sided claudication at 50 feet. She had a previous coronary artery bypass graft surgery. Her serum creatinine concentration is normal and her urine is negative for microalbuminuria.

Which of the following medications would reduce perioperative cardiovascular risk in this patient?

A) Lisinopril
B) Aspirin
C) Atorvastatin
D) Atenolol
E) Clopidogrel

Click here or scroll to the bottom of the page for the answer and critique.

Influenza assessment tools

AMA launches influenza assessment and care coordination Web site

The American Medical Association is providing a comprehensive patient flu health-assessment Web site at http://AMAfluhelp.org to help patients determine the severity of their flu symptoms and share their information with their physicians.

The Web site also provides a set of online tools designed by physicians for physicians to monitor their patients’ symptoms, make better health care decisions and efficiently manage their practice patient flow, according to a news release.

The site can help patients assess their own flu symptoms and offer guidance on whether they should seek care. There is also a choice for pregnant women to evaluate their need for a flu vaccination and for all patients to monitor any vaccine-related symptoms. The site can also generate a doctor's note when it is safe to return to work or school.

AMAfluhelp.org is the first application on a portal designed to support quality of care initiatives to link patients, physicians and other caregivers. The portal will offer applications to support patient/physician communication, minimize redundant testing and allow for continuous monitoring of patients with complex health conditions.

Meanwhile, the CDC warned doctors not to rely on flu tests to decide whether to treat sick patients with antiviral drugs.

Anne Schuchat, FACP, the CDC's director of immunization and respiratory disease, told the New York Times that the tests are often wrong because the nasal swab wasn't done right, or the results take too long to get back. “If you have a person who is severely ill or a person with risk factors like pregnancy, asthma, diabetes, children under 2, and you suspect flu, we recommend any antiviral medicines be given promptly.”

Cardiology

CVD may confer significant risk for hip fracture, study reports

Cardiovascular disease appears to be a significant risk factor for hip fracture and genetics may play a role in who develops the conditions, a study found.

Researchers followed a cohort of 31,936 male and female Swedish twins from the age of 50 years and identified those with cardiovascular disease (CVD) and fractures. Patients were significantly more likely to experience hip fractures if they had a diagnosis of heart failure (hazard ratio, 4.40) or peripheral atherosclerosis (HR, 3.2) or had suffered a stroke (HR, 5.09) or an ischemic heart disease event (HR, 2.32) than those without CVD. Identical twins without heart failure and stroke also had an increased risk of hip fracture after their co-twin had experienced heart failure or stroke, suggesting a genetic association between CVD and osteoporotic fractures. The study appears in the Oct. 21 Journal of the American Medical Association.

Hip fracture rates were highest soon after diagnosis of heart failure or stroke, the authors noted. This may be related to immobilization after a CVD event, they theorized, which leads to decreased muscle strength and stability and increases the rate of bone loss. The study also suggests that people can be predisposed to develop CVD and fractures, as identical twins without heart failure and stroke also had an increased fracture rate after their co-twins were exposed to the diseases.

Men had a higher risk of fracture after stroke than women, which may be explained by men’s greater tendency to fall following stroke, the study reported. The findings should alert physicians to evaluate the future fracture risk of men and women recently hospitalized for CVD and to consider genetic predisposition when evaluating risk, the authors concluded.

Cancer

Breast, prostate cancer screening debated

Current screening practices for breast and prostate cancer were brought into question last week by a special communication in the Oct. 21 Journal of the American Medical Association and statements from the American Cancer Society.

After the introduction of screening, in the form of mammograms and PSA tests, the incidence of both cancers increased and has not returned to prescreening levels or been associated with the expected decrease in regional cancers, the special communication noted. The authors said that screening's contribution to decreased cancer mortality is uncertain and suggested that the lack of effect may be due to increased detection of indolent cancers and the failure of screens to detect the most aggressive cancers.

Changes to the current strategy were proposed: a focus on differentiating and reducing treatment for lower-risk cancers (including not describing these tumors as cancer), tools to support informed decision-making, and prevention efforts (such as finasteride, tamoxifen and raloxifene) targeted at high-risk patients. The authors suggested reallocating some of the $20 billion currently spent on breast and prostate screening in the U.S. to demonstration projects of these new strategies.

An Oct. 20 New York Timesarticle reported that the American Cancer Society was revising its public message to highlight the risks and limitations of screening, but the chief medical officer of the organization denied that any changes were planned, according to later news reports. A statement from the society noted that the advantages of some cancer screens have been overstated, but reaffirmed the ACS recommendations of annual mammograms for women 40 and older and individual decision-making between men and their doctors on PSA testing.

General internists often don't address issues of sexual dysfunction with cancer survivors, a new survey reports.

Sexual dysfunction is a relatively common problem after certain types of cancer, such as breast, prostate and head and neck cancer. Researchers surveyed 319 internists affiliated with a single U.S. medical center to determine how often they discussed issues of sexual dysfunction with their patients who had survived cancer. Two hundred twenty-seven physicians returned the survey (response rate, 71%). The study results appear in a November supplement to the Journal of General Internal Medicine.

Of the 227 responders, 46% reported that they were somewhat or very likely to initiate a conversation about sexual dysfunction and 62% said that they never or rarely addressed the topic. Physicians who spent more time in direct patient care were more likely to discuss sexual dysfunction with their patients, while physicians who reported being inadequately prepared for or lacking formal training in care of cancer survivors were less likely to do so. Sexual dysfunction was more likely to be addressed if physicians believed patients were anxious or fearful about their health or if physicians reported being well prepared to evaluate the long-term effects of survivorship (odds ratios, 2.38 and 2.49, respectively).

The authors pointed out that their study was limited because it surveyed academically affiliated physicians from one part of the U.S. and used self-reported data. In addition, it did not collect data on the types of cancer survivors treated in respondents' practices. However, the authors noted that cancer survivors increasingly receive long-term care from internists and concluded that internists should be better trained in facilitating conversations about sexual dysfunction in follow-up care.

FDA update

Gardasil approved for boys, Cervarix for girls

Gardasil, the human papillomavirus vaccine, was approved for the prevention of genital warts in men and boys ages 9 through 26, the FDA announced recently.

The approval was based on a randomized trial of 4,055 males ages 16 through 26 which found that, in men who were not infected by HPV types 6 and 11 at the start of the study, the vaccine was nearly 90% effective in preventing genital warts caused by HPV types 6 and 11. Studies of immune response to the vaccine in boys ages 9 through 15 found responses similar to those in the older age group, according to an FDA press release.

However, the CDC's Advisory Committee on Immunization Practices decided not to add the vaccine to the recommended childhood immunization schedule for boys due to cost-effectiveness concerns. The advisory panel voted to make vaccination optional when it met last week, Bloomberg News reported on Oct. 21. Gardasil was already FDA-approved and CDC-recommended in girls and young women.

Another vaccine to prevent HPV infection in females was also recently approved by the FDA. Cervarix was approved for use in women and girls ages 10 through 25 and was added to the ACIP recommendations for girls as an equivalent to Gardasil. In studies of uninfected women 15 to 25, Cervarix was about 93% effective in preventing precancerous cervical lesions caused by HPV types 16 and 18, and studies of immune response were similar in younger people, the FDA said.

Use of the product could result in adverse events, including obstruction of blood vessels, which can induce pulmonary emboli or thrombosis and activate platelets and/or neutrophils to induce anaphylactic reactions, according to the FDA. Other adverse effects associated with the injection of particulate matter include foreign body granulomas and local irritation. Clinicians and hospitals should immediately quarantine the product for return.

CMS is also moving forward with plans for the 2010 PQRI program. It plans to again use the claims-based and registry-based reporting mechanism that is currently in place. In addition, CMS has proposed to accept quality measures data gathered from “qualified” electronic health record (EHR) products for a limited subset of 2010 PQRI quality measures. The agency will make a final determination on this once the 2009 EHR data submission testing process is completed and has determined that using the data from “qualified” EHRs again in 2010 will be practical and feasible. Details about the proposed 2010 PQRI provisions are available on the PQRI Web site. These provisions are still in draft form and changes may take place before they are finalized.

Finally, feedback reports and incentive payments from the 2007 and 2008 programs will be ready in October and November. Starting Oct. 12, the incentive payments for the 2008 PQRI program will be made. The re-run incentive payments from the 2007 program will be made starting in November for any clinicians who qualify. The 2008 feedback reports and 2007 re-run reports will both be available starting in October. For information about how to access these reports, please check the quick-reference guide.

From the College

College Fellows, Masters elected to Institute of Medicine

Six College Fellows and Masters have been elected to membership in the Institute of Medicine of the National Academy of Sciences (IOM).

Russ B. Altman, FACP; Donald S. Burke, FACP; Roberta B. Ness, FACP; Nancy N. Nielsen, MACP; Griffin P. Rodgers, MACP; and R. Brian Haynes, MACP, were among those honored at the IOM's 39th annual meeting, announced a recent press release. The IOM recognizes those who have shown outstanding professional achievement and commitment to service and have contributed to the advancement of the medical sciences, health care, and public health. Elected members contribute to the IOM's work by serving on IOM committees, boards and other activities.

College Master to continue as director of AHRQ

Carolyn M. Clancy, MACP, will continue her term as director of the Agency for Healthcare Research and Quality, the agency recently announced. Dr. Clancy was first appointed to the office in 2003 after serving as the agency's acting director and as the director of its Center for Outcomes and Effectiveness Research. Dr. Clancy, who is a general internist and health services researcher, was elected a Master of the College in 2004.

Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Our guest judge, John Reed, FACP, has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

"That’s why I’m called an in-ternist."
"What forms do I need to fill out to get preauthorization on a second inbox?"
"Livin' the dream—how about you?"

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Nov. 2, with the winner announced in the Nov. 3 issue.

Perioperative β blockade has been shown to decrease in-hospital and 30-day mortality rates in patients with peripheral vascular disease. Aspirin and clopidogrel appear to be beneficial to prevent long-term cardiovascular events. Without other indications, such as atrial fibrillation or deep venous thrombosis, warfarin is not routinely used in patients with peripheral vascular disease. Although lipid management is important for long-term treatment of patients with peripheral vascular disease, there is no proven benefit for pre- or perioperative use. In this patient without a history of hypertension, diabetic nephropathy, or prior myocardial infarction, there is no proven benefit for an angiotensin-converting enzyme inhibitor.

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Copyright 2009 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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